Documenting consent

It is important to make notes in the patient's medical record about the consent discussion. The note might contain the following:

major risks discussed

minor but important risks mentioned

any questions the patient asked

answers given

the patient's apparent understanding (especially if it is a young person, or one whose mental capacity or competency might be questioned)

any handout materials provided to the patient

Print material, videos, or other handouts support the consent discussion but do not replace it.

What is the purpose of a consent form?

A consent form itself is not the consent.

The dialogue with the patient is the key element of the consent process.

Follow hospital requirements, if applicable, for completing a consent form.

In many Canadian jurisdictions it is now a legal requirement that a consent form be completed before any surgical procedure is undertaken in a hospital. The consent form itself is an acknowledgement and serves as documentary evidence that the explanations were given and that the patient agreed to what was proposed.

In witnessing a signature, the witness simply confirms the identity of the patient who signed the document. The witness's role has no other legal significance.

Key concepts

Patients have the right to decide on investigations and treatments (patient autonomy).

Mentally capable patients have the right to refuse or withdraw consent for investigations and treatments.

Consent must be voluntary and informed.

Patients must have the capacity to give consent.

The physician is required to provide information that the "reasonable" patient would want or need to make a decision.